The county elections official’s statement to the Secretary of State of the number of signers shall be in substantially the following form:

statement of county elections official of number of signers

I, County Elections Official of the County of ____, hereby certify that I have examined the ____ hereto attached filed on behalf of ____, candidate for nomination to the office of ____ at the primary election to be held on the __ day of ____, 20_, and that the total number of signatures which I have not marked “not sufficient” is ____.

Dated this __ day of ____, 20_.

__County Elections Official

(seal)By _________ Deputy